Medicare Rx Enrollment Rules

The Centers for Medicare and Medicaid Services (CMS) has finalized a rule requiring physicians and other professionals who write prescriptions for Part D drugs to:

Be enrolled in Medicare in an approved status, or

Have a valid opt-out affidavit on file for their prescriptions to be covered under Part D.

This new rule is similar to a rule adopted previously by CMS that requires all Eligible Professionals who order or refer Medicare patients to be enrolled in Medicare Part B as a condition for the physician to whom the patient was referred to get paid by Medicare.

CMS will delay enforcement of this rule until January 1, 2016. The rule was delayed twice before, originally being scheduled to take effect on June 30th and then delayed until December 1st. Eligible Professionals who prescribe Part D covered drugs should either submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors (MACs) by June 1, 2015. This will ensure that there is sufficient time to process the applications before the January 1, 2016 deadline.

As with the Ordering/Referring policy, if an Eligible Professional is only enrolling in Medicare for purposes of meeting the new prescribing requirement (i.e. will not submit claims for Medicare reimbursement), then the provider should use the 8550 enrollment application rather than the 855i.

After concerns about beneficiary access, CMS announced that Part D sponsors will be required to cover a provisional supply of drugs for three months for prescriptions that are written by physicians or eligible professionals who are not in compliance with these new rules (enrolled in Medicare or have a valid opt-out). Beneficiaries will receive written notice that their prescriptions are being covered on a provisional basis and be encouraged to find a new prescriber.

In order to prepare prescribers and Part D sponsors for the deadline, CMS is releasing an enrollment file online that identifies physicians and eligible professionals who are enrolled in Medicare in an approved or opt-out status.

This list will be available here and will be updated every two weeks through the January 1, 2016 enforcement date.

The official CMS announcement can be found here.Subsequently, CMS announced revisions of the rule here.